A nurse is collecting data from a client who is recovering from a recent stroke.
Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

Coughing while eating.

Fine motor tremors.

Facial flushing.

Urinary incontinence.

Answer and Explanation

The Correct Answer is A

Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.

Choice B is wrong because fine motor tremors are not related to speech or language problems.

They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.

Choice C is wrong because facial flushing is not related to speech or language problems.

It may be caused by high blood pressure, fever, anxiety or other conditions.

Choice D is wrong because urinary incontinence is not related to speech or language problems.

It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.

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Correct Answer is B

Explanation

Ask the client to empty their bladder.

This is because a full bladder can interfere with the pelvic examination and cause discomfort to the client. The nurse should also instruct the client to avoid douching, using tampons, vaginal medications, sprays, powders, birth control foam, cream, or jelly for at least 24 hours before the exam.

Choice A is wrong because the client should be placed in a lithotomy position, not a prone position, for a pelvic examination.

Choice C is wrong because douching can alter the normal vaginal flora and pH, and increase the risk of infection.

Choice D is wrong because placing the client’s arms over their head can tighten the abdominal muscles and make the examination more difficult. The nurse should ask the client to place their arms at their sides or across their chest.

A. Isopropyl alcohol. B. Chlorhexidine. C. Hydrogen peroxide. D. Bleach.

Correct Answer is D

Explanation

Bleach.

According to the CDC, bleach is an effective disinfectant for environmental surfaces contaminated with blood or body fluids from a person with AIDS or other bloodborne pathogens. Bleach can kill HIV and hepatitis viruses when used in a 1:10 dilution with water.

Choice A is wrong because isopropyl alcohol is not recommended for disinfecting environmental surfaces. It can evaporate quickly and may not have enough contact time to kill the pathogens.

Choice B is wrong because chlorhexidine is an antiseptic, not a disinfectant. It is used for skin cleansing or wound irrigation, but it is not effective against spores or non-enveloped viruses.

Choice C is wrong because hydrogen peroxide is a low-level disinfectant that can be inactivated by organic matter.

It is not suitable for disinfecting surfaces contaminated with blood or body fluids.

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A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse at a long-term care facility is caring for a client who has AIDS. The client accidentally spills the contents of their urinal on the floor. After cleaning up the spill with soap and water, the nurse should apply a solution of water and which of the following disinfectants to the floor?

Correct Answer is D

Explanation

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A nurse is collecting data from a client who is recovering from a recent stroke.
Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?